Galanti went on to identify three major issues in dealing with patients with varying cultures and belief systems: Conflicting beliefs on health and illness, lack of trust in the healthcare system, and differing time orientations. She reminded the audience, "Not everyone who utilizes our medical system necessarily shares our beliefs regarding health and illness."

One example of conflicting cultural beliefs is the "evil eye," often seen in Hispanic and Middle Eastern cultures. Galanti shared a story of a home care nurse who admired the child of a patient. In Hispanic cultures, this is seen as calling the attention of evil spirits to the child, or "giving it the evil eye." The nurse obviously meant no harm to the child but, as Galanti explained, "because of this cultural misunderstanding, there was a decreased level of trust between the nurse and the family."

Galanti suggested using what she calls the "4 C's of Culture" to gain insight into the patient's perspective.

What do you CALL your problem?

This allows the patient to express what they think the problem might be in their own words. Galanti recommended the book The Spirit Catches You and You Fall Down as a perfect example of what can happen when healthcare professionals don't take the time to ask this question. The book tells the story of a young Hmong girl who was brought into the ER, suffering from seizures. At that point, as Galanti described it, "everything that could go wrong did go wrong." Due to miscommunications, mistrust and misunderstandings on the part of the family and her physicians, the girl eventually died.

What is the CAUSE of your illness?

This allows the patient to talk about what they may have done to bring on the illness. Galanti provided an example of an African-American woman who refused an angiogram because she thought she had sinned, and God was punishing her with the illness.

How do you COPE with the problem?

This allows the patient to talk about traditional remedies they may have tried. Such remedies can range from herbs to acupuncture to cupping. Asking about these remedies is important because it can alert you to possible bad interactions with Western medicines. In the case of cupping, asking about coping strategies may stop you from reaching the conclusion that the patient has been abused, since the technique can leave bruise-like marks on the body. As Galanti explained, "They key is all in how you ask this question. You don't want to come across as being mistrustful or dismissive of traditional remedies."

What are your CONCERNS about the problem or treatment?

This provides the patient or family members to tell you, in their own words, what worries they may have. In the case of the young Hmong girl, taking the time to allow the parents to explain their concerns in their own words might have allowed healthcare providers to better understand that the family viewed their daughter's condition as one of the spirit, and not just the body.

Galanti noted that a failure to consider these four C's of culture can lead to the next major issue in cultural considerations - patient mistrust of the healthcare system. One example she shared was within the African-American population. She noted that there has been a long history of mistreatment and racism within the healthcare system, including the infamous Tuskegee Experiments, in which a group of African-American men with syphilis were allowed to go untreated so that doctors could study the course of the disease. "The key here is to acknowledge and apologize for any slights, even if completely unintentional," she noted.

In the case of Hispanic patients, a failure to take a personal interest in the patient can also lead to mistrust. Healthcare providers, particularly doctors, are expected to show personalismo toward the patient and family. The sort of professionalism that it expected within Western medicine is seen by the Hispanic patient as uncaring and impersonal.

The final issue with cross-cultural differences that Galanti discussed was that of time orientation. Patients with a future-time orientation have an interest in preventive medicine - taking action now to stop future illness. Those with a present-time orientation, often the poor or minorities, may have difficulty imagining into the future because they are so concerned with what is immediately affecting them. Finally, patients with a past-time orientation are most concerned with holding to traditions and values that have been passed down to them. Oriental medicine is a good example of this type of orientation.

The key to helping patients with a present- or past-time orientation understand the benefits of preventive medicine is to tie it to something concrete that has meaning for them. "Being able to dance at a daughter's wedding or play with future grandchildren has meaning for these people. It can often be the incentive they need to take better care of themselves," Galanti noted.

She wrapped up the discussion by urging participants not to be afraid to ask questions, even if they are afraid they will offend patients and family. "Cultural factors such as beliefs about health and illness, issues of trust and expectations of providers, and time orientation all play an important role in health literacy. We need to be able to understand these things to help our patients."

Talking to Patients About the Risks and Benefits of Treatment
Angie Fagerlin, PhD

Health literacy is not just about words. It can also be about numbers and understanding what those numbers actually mean. Fifty percent of people cannot calculate the tip for a meal or the sale price for an item. Attempting to comprehend risks for side effects or a bad outcome, by comparison, can be utterly bewildering for the average patient.

According to Angie Fagerlin, PhD, of the University of Michigan, helping people understand percentages, risk ratios and odds is all in how you present the data. She noted, "People are far more likely to admit to problems with numbers than they are to reading difficulties." A perfect example of this is how many people joke about their difficulties understanding math.

To illustrate the numeracy problems most people have, Fagerlin asked the audience two questions:

·         What is a bigger risk: 1%, 5%, 10%? (Answer: 10%)

·         What is a bigger risk: 1 out of 10, 1 out of 100, 1 out of 1,000? (Answer: 1 out of 10)

While everyone in the audience could easily answer the first question, there was some hesitation as to the correct answer for the second question. Despite this obvious difficulty people may have understanding numbers, Fagerlin explained, "We still owe it to patients to give the numbers when they are available."

The Impact of Framing

Fagerlin went on to discuss studies that looked at framing of numerical data and the difference it makes in patient perceptions. One study in the New England Journal of Medicine (McNeil, et al., 1982) asked a group of people to imagine being told that a particular surgery for lung cancer had a 90% survival rate. They were then told to imagine that they were told that the surgery had a 10% mortality rate. Even though both percentages mean the same thing, significantly more people (26%) opted for the surgery if they thought it had a 90% survival rate. Fagerlin added that the participants in the study were business students, patients and even physicians: "We would not consider these people to have low literacy skills." 

In another study, a group of people were told about a headache medicine that reduced the frequency and severity of headaches for 65% of patients. However 10% of patients who took the medicine got a blistering rash. The people were then told that 65 out of 100 patients showed improvement with the medication, but that 10 out of 100 got the rash.

The results showed that people with lower numeracy skills were more likely to perceive the medication as less risky if the data was presented in a percentage format than in a frequency format. For those with high numeracy skills, there was no difference in risk perception depending on how the data was presented. Fagerlin added that the difference in risk perception is one of how concrete the concept might be. "Participants could easily picture 10 people having this rash. However, they have difficulty visualizing what 10% looks like."

The Power of Labels

Fagerlin then discussed how being given a label can affect patients' perceptions. The classic example of this is the common misperception that a "positive" result for cancer screening is a good thing. "When you attach a label to the outcomes," she added, "people will overlook the details."

To illustrate this, Fagerlin cited a study in which two groups of women were given the risk of a complication with their pregnancy. One group was only presented with the risk information, while the other group was also told that their results were either "normal" or "abnormal."

When offered an amniocentesis, those high-risk patients who were also given a label of "abnormal" with their risk estimate were more likely to agree to the test than those who were only given the risk estimate. Similarly, the low-risk patients were less likely to want an amniocentesis if they were told their results were "normal" than if they were just given the risk estimate. Fagerlin added, "People will skim over the details and only remember if the results were good or bad."

A Picture is Worth a Thousand Words

It's not just the words, but the images that can also make a difference with understanding risks and benefits. Fagerlin discussed a study in which participants were given information on the risks and benefits of two different drugs for clogged arteries. They were randomized to receive this information in one of five different ways:

·         bar graph

·         pie graph

·         modified pie graph "clock graph"

·         pictograph

·         modified pictograph "sparkplug"

Participants were then asked a series of questions, some of which were asking for the gist of the information received, and others asking for specific verbatim knowledge. Fagerlin noted, "Compared to other graph formats, pictographs are the only graph that results in the best gist and verbatim knowledge."

Presentation Matters

In conclusion, Fagerlin emphasized that it's not just enough to give the patient information. You must also be aware of the way in which you are presenting it. Research has shown that the decisions patients make about their healthcare can easily be influenced by what they perceive to be the risks and benefits.

"We can easily give patients so much information that they will miss the key points of what we have to tell them. It is our responsibility to think of how we present them with this information."

Field-testing Your Patient Education Materials
Lorraine Wallace, PhD

Lorraine Wallace opened her presentation with three objectives:

• Explain the importance of field-testing
• Describe how to plan, develop questions for, and facilitate a fielding testing session
• Describe how to revise (and re-evaluate) based on findings generated during field-testing sessions.

She talked briefly about readability testing. She then discussed formatting and layout evaluation tools that can be used for assessing document complexity or the need for readers to look outside the document for important information. Though there is a learning curve for applying this formula, Wallace said it is particularly good for documents like healthcare enrollment forms She also talked about two tools for assessing questionnaires, QUAID and the Questionnaire Appraisal System. All of these are important to do before you start field-testing.

Wallace credited the Doaks with much of what she would say about field-testing. She included a definition: "Learner verification and revision is an interview procedure to verify the suitability of a health instruction with the population who is to use it." (Doak C, Doak L, Root J. Teaching Patients With Low Literacy Skills, 1985) Field-testing is important because it uncovers specific content that patients may not understand. Wallace offered tips for when, how, and where field-testing should be carried out.

The logistics of field-testing included identifying key points you want the users to understand and likely trouble spots. You also need to develop questions that test understanding of those key points, determine the likely influence of the information, and identify variations in interpretations. You may need to ask questions that get at the attractiveness of the message, the cultural suitability to the audience, and the audience's self-efficacy.

Wallace recommended the use of open-ended questions. A helpful tip was to ask respondents to make suggestions by writing directly on the documents under review. She explained, "Patients are very receptive, appreciate the opportunity to help and will give excellent information. Patients are also very responsive when you tell them their efforts will be helping other people."

Wallace gave an example of the process of field-testing in the development of a low literacy pain contract. The first step was to gather a representative sample of similar materials, most of them written at a college level.

The next step was to revise. Interviews with patients involved identifying a pool of patients who matched the demographics of the intended audience, getting informed consent, and administering a brief, non-intimidating literacy assessment. Wallace showed sample questions such as: "Please read this statement aloud. Next, please tell me in your own words what this statement means to you," and "What else should go here?" The interviews were audiotaped and scored by the researcher and another person. After about 10 interviews, the researchers reached a threshold of repeated information.

The next steps were revision and another round of interviewing. By the end, user scores indicated 85% overall for comprehension, and as high as 100% for some users.

Wallace showed an example of some of the elements of a scoring system for another project on the development of an anti-retroviral pamphlet. It included the two main components of the ability to locate information and the ability to understand it. Examples of knowledge-testing questions were: "Was the item understandable?" and "Did you have to read the item more than once to understand it?"

Wallace recommended paying attention to the majority of responses. Some comments need to be taken with a grain of salt. If eight of 10 patients say they did not understand something, then you need to revise the document. If responses are all over the place, then you need to keep going with your testing. Workshop participants critiqued a factsheet from JAMA about epilepsy, and discussed how they would go about making revisions and doing field-testing.

Wallace also talked about using focus groups, and showed examples of how focus groups were successful at revising complex information about the genetic risks for breast cancer. She discussed the process of ranking the importance of information and then asked participants to rank the headings in an otitis media brochure. In response to a question about the use of the technical term otitis media, Wallace recommended bracketing the words and using a common definition. She also recommended the use of glossaries. Research is still ongoing about the best placement on the page for such a glossary.

The session ended with questions and answers containing practical information as participants clearly sought to find ways to incorporate field-testing into their organizations. Questions included paying patients to participate in field-testing (a $5-$10 gift certificate is useful and reasonable if you can afford it) and the real-world situation of not being able to test every single piece of literature.

In conclusion, Wallace reiterated that readability formulas are a first step, and that the clearer your piece is to begin with, the less field-testing you may have to do.

Implementing Health Literacy Strategies in a Group Health Plan Setting
Bernadette Hefflefinger, Peggy Payne, Ann Nakahira, PharmD

One area of the healthcare industry that would appear to benefit from health literacy is in insurance companies. The truth is that most people find anything having to do with insurance daunting, whether it is enrollment, benefits, coverage or costs. One survey found that Americans list insurance companies among the five most frustrating organizations to deal with. Furthermore, according to another study, "Most consumers are unaware of how much major medical procedures actually cost: three out of four consumers report having 'no idea' how much they cost." (www.mckinseyquarterly.com/The_role_of_emotions_in_buying_health_insurance_2352)

In this panel, representatives from three different healthcare insurance companies spoke about each of their efforts to tackle the issue of health literacy. Bernadette Hefflefinger (Wellpoint), Peggy Payne (Cigna) and Ann Nakahira, PharmD (UnitedHealth Group) all shared stories of how their organizations got started with health literacy and what they are doing today.

Wellpoint

Bernadette Hefflefinger started off by listing the goals of the health literacy program within her company, Wellpoint. Its health literacy efforts began in 1994, when the company started producing Medicare patient material written at a fourth- to sixth-grade reading level. By 2010, the company's accomplishments included:

• collaboration with Wisconsin Literacy to develop a health literacy toolkit for statewide distribution
• hosting four educational webinars with speakers from the AMA, CDC, the legal field, and other health plans
• developing a plain language newsletter for associates
• developing a multifaceted plain language initiative
• forming a Plain Language Squad to offer help to departments
• developing a health literacy/plain language website
• compiling an internal thesaurus of alternate words for medical/technical terms
• incorporating Plain Language Standards Guide into corporate Brand Writing Style Guide
• presenting a plain language business case to executive leadership. Two executive VPs, who report to company president and CEO, have given their support

Hefflefinger added that bringing about change is never easy but the company didn't allow challenges to derail its efforts. There were definitely some roadblocks and detours had to be taken to get to where things are now. She added, "Some critics of plain language claim that plain language is 'dumbing down' or 'it's not professional.' Writing in plain language requires the use of the barest minimum of words that best express the message you want to convey. That kind of writing takes skill and a lot of practice."

CIGNA

Peggy Payne from CIGNA was next up. After a brief introduction of the organization, she provided a history of its health literacy efforts. A full-time health literacy position was created, along with a workgroup to identify health literacy needs and resources. Webinars, web-based learning courses and writers' training courses were later developed. Some of CIGNA's current health literacy projects include:

• A plain language policy
• Company awareness campaigns
• Words We Use guidelines
• Guidelines for writers

Payne added that these efforts have paid off for the company. In various CIGNA member surveys, data has shown improved usefulness of print information, increased clarity of pre-enrollment materials, and an increase in CIGNA members who reported learning something new in their disease management programs.

One organization that can help insurance companies incorporate health literacy efforts is the America's Health Insurance Plans (AHIP) Health Literacy Task Force. Its mission includes:

• Increasing awareness and understanding among AHIP member companies and key stakeholders of the need for clear health communication
• providing companies with tools to get started and advance their programs
• sharing best practices

Payne added that AHIP has a toolkit available. You can find out more by visiting http://www.ahip.org/healthliteracy/toolkit.

UnitedHealth Group

Ann Nakahira, PharmD, discussed UHG's Health Literacy Innovations Program. She said that its mission is: "Understanding the language of health is a key to living a healthier life." The program started about two years ago in three of UHG's business areas. It now covers five business areas and has one dedicated full-time employee.

While much of UHG's efforts are similar to those of Wellpoint and CIGNA, Nakahira chose to focus on some of the obstacles and barriers that have to be considered when incorporating health literacy into an insurance company. These may include:

• I don't understand what you are saying
• We already create reading materials at the 6^th-grade level
• It could cost us time and resources to make changes
• Where's the research?
• Aren't we doing that now?
• How or what can we do to make the change?

Nakahira added, "You may need to use different levers for different parts of the company to overcome these obstacles." She suggested using the National Action Plan as a roadmap to incorporate health literacy into your organization.

In wrapping up the session, Hefflefinger reminded the audience, "No one plan, no single formula is best for everyone or every single company. WellPoint, CIGNA and UHG are at different points or junctions in their health literacy journey. They are taking different roads leading to improved health literacy."

Using Social Media Tools to Reach People with Health Information
Jennie Anderson, MPH

Expanding on Lee Rainie's discussion of the demographics of the e-patient, Jennie Anderson took things one step further by talking about how to reach those e-patients using social media. As a demonstration of the sorts of social media tools that have now become commonplace, she asked the audience to stand up if they had used certain social medial tools or devices. As expected, most everyone stood up when asked if they had a cell phone. When asked about use of e-mail, about the same number remained standing. A few more sat down when asked about Facebook, and then Twitter. Several more sat down when asked about more advanced social media tools such as location checkers or RSS feeds.

Anderson reminded the audience that social media tools are simply another communication channel to reach your audience. "People can respond more quickly. You will get greater interaction and faster response."

She then went on to cite some of the same statistics Rainie had provided earlier as to the demographics of people using social media. Eight in 10 people have used the Internet to search for health information. Even more importantly, Anderson added, "Many e-patients say the Internet has had a significant impact on the way they care for themselves or for others."

This online use of healthcare information has created a culture of what Anderson called "peer-to-peer healthcare." Again citing some of Rainie's data, Anderson noted:

• One in five Internet users has gone online to find others like them
• One in four Internet users living with a chronic ailment (23%) say they have gone online to find others with similar health concerns

How is the health literacy field using new social media to reach these e-patients? Anderson provided some examples, including both the Institute for Healthcare Advancement and Health Literacy Missouri twitterfeeds. One of the more interesting examples she showed was from her own organization, John Snow, Inc. It is an interactive map that shows the user where to find their nearest HIV testing center. It will also show the location of the nearest substance abuse treatment, mental health and family planning centers.

Other websites will provide health tips and reminders via text messaging. One study in the journal Pediatrics (http://pediatrics.aappublications.org/content/124/5/e844.long) showed that when liver transplant patients received medication reminders via text messages, there was a significant increase in medication adherence.

Anderson noted that even the National Action Plan refers to the use of social media to expand the field of health literacy. For example:

• Engage professional associations (e.g., the Association of Healthcare Journalists) and social media users (e.g., bloggers) in raising awareness of and action on health literacy issues (pg 22)
• Use technology, including social media, to expand patients' access to the health care team and information (pg 27)
• Use libraries and librarians to locate good quality, relevant health information. Take classes offered by librarians on Internet and social media tools. (pg 60)

Understanding how people use social media and why your organization should use social media are very important. However, the key is transforming this knowledge into action. Anderson provided a helpful way for organizations to determine how they should best use social media:

People: Who are the people you are trying to reach?

Objectives: What do you want to accomplish?

Strategy: How will you meet your objectives?

Technology: What is the best technology that will allow you to accomplish your objectives?

Using this method, Anderson presented a model of how to use your time for your social media strategy:

Obviously, the reason for implementing such a social media strategy is to get results. Anderson noted that it can be anything from measuring web traffic using Google analytics, to measuring which tweets are the most popular, to monitoring any videos that might have gone "viral."

An example of such a video project is Dan Savage's It Gets Better Project (www.itgetsbetter.org). As a response to the sudden upsurge in gay teen suicides due to bullying, author Dan Savage started the video project to reach out to gay teens and tell them that things will get better if they can just hold on. Eventually, celebrities, everyday people and even President Obama all contributed videos to the project. 

The project served as a perfect example of Anderson's last bit of advice: "Ultimately, the message you are sending is what matters most. You are doing all this to reach out to people. Remember to step away from the tool itself and always bring it back to the message."

Podcasting: How to Create Meaningful Audio Interviews
Helen Osborne

As several other sessions at the conference have mentioned, our society is increasingly becoming more and more mobile. In addition, they are more likely to seek out information while on the go. One of the ways in which to provide listeners information is via podcasts - the modern-day version of radio talk shows. Podcasts are like radio shows in that they have informational or entertaining audio content. But unlike radio, podcast listeners choose when, where, and how to hear these shows. Helen Osborne, host and producer of the podcast Health Literacy Out Loud, provided an informative session on not only how to do a podcast but also why you should consider working in this medium.

She started out by explaining how she got started making podcasts. In 2006, she was already interested in health literacy and was looking for a means to inform people on the topic. She joked, "I was determined to be the Oprah Winfrey of health literacy."

She started making her own CD series, but found them very expensive to produce. At that point, she first found out about podcasts and was "quickly smitten" with the concept. Since her first podcast in 2008, she has now reached more than 50,000 listeners.

Osborne then went on to list some of the reasons those in the health literacy field might consider producing podcasts:

• As many as 6.5 million people listen to podcasts every day, many of whom are in the higher income bracket.
• People can listen to podcasts at times they find convenient.
• Podcasts can stand alone or be offered with other ways of learning such as with written transcripts, websites, and ways to learn more.
• You can provide a platform for a wide variety of experts
• You open doors to conversations on a wide range of timely topics.
• The power of audio is phenomenal. It is a very intimate "in your ear" experience.

Osborne also mentioned several drawbacks, the biggest of which can be the initial layout of money to purchase needed equipment. There is also a huge time commitment involved. You may also need to hire an editor if you don't know how to do this yourself.

There are many things you need to think about if you want to start doing your own podcasts. Osborne suggested first thinking about what format you wish to use. A lecture format is one person speaking on a single topic for the entire show. The drawback, as Osborne explained, is that it can get boring for the listener. A radio format would consist of several different stories, which might hold more interest. Finally, there is the interview format, which allows for even more variety from different interview subjects.

There are also time considerations. Osborne suggested five minutes as the lower limit for a podcast and anywhere from 20 to 30 minutes as a maximum. In terms of production frequency, Osborn suggested to produce at least a show a month "to build a loyal audience," but not to try to put out more than one a week, lest you burn yourself out.

She then moved on to a quick demonstration of what she jokingly called "her toys." These would include Skype (for recording interview calls), software to save the recordings, file transfer software that is robust enough to handle big audio files, and editing software if you want to do this yourself.

Having covered the technical basics, Osborne then moved on to a live demonstration with Cliff Coleman, MD, as her interview subject. She noted that under normal circumstances, she would speak to the interview subject beforehand to brainstorm possible questions, "although I do like to keep people on their toes by throwing them an unexpected question." She also stressed the importance of getting the subject's consent before properly starting the interview.

She started with a quick introduction, and then moved right into asking Coleman questions about his efforts to teach health literacy to medical school residents. He noted that while health literacy is the easiest concept in the world to explain, the hardest part is getting the students into the room. He added, "Health literacy is a problem of us, not them [patients]."

Osborne then let some of the session participants ask Coleman questions so that they could get a feel for how to conduct interviews. Coleman commented afterward that even he was excited about the possibility of incorporating podcasting into his own health literacy efforts.

In summary, Osborne noted that participants may be wondering just what they should do with all of the information she had given them. "Really, it's not about me. It's about my passion for health literacy," she noted. "Find your passion and find your style, and there is a way to make it work for you in podcasting."

Empowering Patients: A Health Literacy Toolkit to Engage Community Groups
Stan Hudson and Diane Smith, PhD

Stan Hudson and Diane Smith, from Health Literacy Missouri and the University of Missouri respectively, gave a thorough overview of an innovative initiative to educate and empower patients. The program uses an adaptation of the simulated patient model used in many medical schools.

Hudson began by saying that they started out with the notion that they would create provider trainings. He then asked how many of the audience members were healthcare providers, followed by asking how many were healthcare consumers. The response to the latter question was almost 100%. Thus, he said, "It made sense to focus on the consumer side of the patient/provider equation, by training patients to understand and act on complex health information as well as by training providers."

Hudson and Smith briefly introduced the method of using simulated patients to train medical professionals in medical schools. In this setting, people are trained to act in scripted, patient roles in order for medical students to be able to practice communication skills. Following videotaped sessions with simulated patients, students receive feedback from a coach. Using simulated patients was a great way to train physicians in a shame-free environment,

Smith and Hudson then wondered: Why not train medical professionals as simulated providers. Their intent was to challenge the well-known phenomenon of clients feeling unable to ask questions in the doctor's office. Using simulated providers could teach patients how encourage and actually train their doctors to have good communication skills, as well as helping patients learn to get comfortable asking questions themselves.

The rest of the session was devoted to giving details of workshop preparation, implementation and follow-up activities. The first steps are to recruit a group and choose an appropriate patient case. Many different community groups are suitable for these workshops, including nursing homes, faith-based groups, and disease support groups. Meeting with the group, even for 15-20 minutes can help you decide what health needs and challenges it faces. You can thus tailor the workshop to those needs. Hudson and Smith have worked with three cases, on asthma, hypertension, and diabetes.

The second step is recruiting people to be simulated health professionals, and then training those individuals. While it is not necessary to use only healthcare providers, it's a good idea to include some healthcare professionals. They know the jargon and have exposure to real situations. Hudson and Smith found that it is practical and useful to work with medical students, for example. The students find it very useful as well.

Facilitators for the workshops may need to be trained as well. Two facilitators are needed for each workshop.

Final preparation steps include marketing and promotion to the community groups. You may also need to consider the need for day care or translators, as well as whether or not to provide food.

Following a demonstration with a volunteer from the audience, Hudson and Smith gave a detailed account of the actual workshop implementation. They began by conducting a pre-survey, introducing health literacy, and encouraging learners to share their own stories. They suggested reading the survey aloud to surmount reading issues.

They gave two cautions. First, don't actually use the words "health literacy" either in promotions or in the actual workshop. Instead, focus on "communicating with the provider" and talk about health literacy through story and example The second caution was that you may need to cut participants off after 20-30 minutes of sharing stories, so as to move things along.

Prior to doing a demonstration, the facilitator discusses four key health literacy techniques that they would like participants to use and learn:

• Use of plain language and common analogies
• The self-initiated brown bag review of medication
• The self-initiated teach back
• Focusing on key messages and repetition

This is followed by simulated case sessions with smaller breakout groups and small group discussions. One person from the group is a volunteer patient in a session with the simulated doctor. During the session, the facilitator takes notes and observes, using a time-out to interrupt the role play if necessary.

After a 10- to 15-minute session, the volunteer and healthcare provider are encouraged to discuss their thoughts, questions and comments. The rest of the group is invited to share as well. Participants may need to be reminded that the purpose of the training is not to elicit specific medical details, but to focus on communication. Requests for information can be handled by suggesting that patients take those questions back to their doctors. The final step of the workshop includes debriefing and conclusions with the whole group, and administering a post-workshop survey. Workshop facilitators are then asked to report on the process, and submit completed surveys.

Hudson and Smith provided both a detailed manual and a CD with instructions for conducting "Straight Talk With Your Doc" workshops. They encouraged the audience to conduct workshops and return results to the data team at Health Literacy Missouri. Efforts are being made to show that this kind of training can help clinics do well on the CAHPS, which looks at levels of patient satisfaction, as well as being effective at reducing costs and time for healthcare organizations.

Closing Panel
Michael Villaire, MSLM; Toni Cordell; Gloria Mayer, RN, EdD; and Cliff Coleman, MD

Having spent an exciting three days learning all about health literacy, it was now time for the concluding panel to wrap things up by sharing their thoughts. All the panelists marveled at just how far the field of health literacy has come in just 10 years.

Dr. Coleman, one of the plenary speakers, noted, "It amazes me just how far health literacy has come in 10 short years. I am incredibly excited for what will be coming in the next 10 years."

Mayer noted that she has seen a tremendous shift in the audience that the conference has attracted over the past 10 years. When the conference first started, most attendees were researchers because the health literacy field was so young. Mayer added, "Now, it seems to have shifted to mainly practitioners out in the field. We've seen that it is really practitioners who are demanding the information on health literacy. It really can just be something as small as sharing resources that can have a tremendous impact for those practitioners. The word is getting out there about health literacy."

Mayer also commended the work Dr. Coleman has been doing to make health literacy an integral part of the medical school curriculum as a perfect example of the shift that has taken place from researcher to practitioner. "The researchers have laid the groundwork by doing the studies and showing that efforts to improve health literacy do make a difference. Now, practitioners are taking that out into the field and seeing the results for themselves. Dr. Coleman is now passing that knowledge along and making it institutional, so that future generations of physicians will benefit."

Cordell added that from a patient perspective, it is amazing to consider how far the field of health literacy has come, even though it is still in its infancy. She added that she wished the field had been more fully developed when she was younger because it might have made things easier for her in navigating the health care system. However, she noted that the field still has a way to go. "I've been known to rewrite healthcare forms if I don't understand them. I'll make a note saying 'I don't understand this. What does this mean?' And so far, nobody has ever questioned me or called me on it."

Villaire wrapped up the conference by once again reiterating the purpose of the conference: "This conference has always prided itself on being operational. It needs to reflect what is really going on right now in the health literacy field and healthcare as a whole. We really hope each of you takes home the information you got here and starts using it in your practice."

He added that the most important thing to remember is that health literacy needs to be a part of everything in the healthcare field, even if that may not be obvious. "We need to make this an integral part of healthcare. It really does need to become a part of everything we touch and everything we do."

Villaire's remarks may be the best way to sum up not only the past 10 years of health literacy, but Dr. Coleman's hope for its future: that it becomes an integral part of the healthcare field as a whole.